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Clinical Medicine > Peripheral Vascular Disease > Flashcards

Peripheral Vascular Disease Flashcards

1
Q

Indications for carotid bifurcation imaging:

A
  1. ) stroke risk factors: neruo symproms (TIA), moderate-severe PVD, retinal exam findings
  2. ) Symptomatic patients: contralateral weakness/sensory deficits
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2
Q

Amourosis Fugax

A

Shade coming down over the eye

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3
Q

Hollenhorst plaques

A

cholesterol deposits on the retina.

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4
Q

Carotid bruits

A

More predictive of CAD/MI risk than stroke. Sensitivity is poor but specificity is high

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5
Q

Carotid Artery Disease treatment

A

treat HTN, hyperlipidemia, DM. Smoking cessations. Aspirin or clopidogrel.

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6
Q

Carotid Artery indications for surgery

A

if greater than 70% occluded. Carotid endarterectomy is preferred but a stent can be used for symptomatic patients with larger risk factors for surgery.

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7
Q

Aneurysm

A

Abnormal dilation of a vessel. 1.5-2 times the normal size.

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8
Q

Aortic Aneurysm

A

Due to degeneration and remodeling of the aortic wall. Usually atherosclerotic.

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9
Q

Ascending aortic aneurysm symptoms

A

Compression (swelling in head/arms), pain (chest/neck/back), hoarseness (RLN), aortic valve regurgitation.

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10
Q

Arch/Descending aortic aneurysm symptoms

A

Wheezing, coughing, SOB, hemoptysis, hoarseness, dysphagia, chest/back pain.

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11
Q

Aortic aneurysm Surgical indications

A

larger than 5-6cm. Marfans at 4-5cm. Factors such as location and involvement of other vessels.

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12
Q

Aortic aneurysm medical management

A

Beta-blockers, Angiotensin II receptor blockers (retards growth and lowers BP), statins, smoking cessation, BP goal of less than 140/90.

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13
Q

Aortic Dissection

A

Tear into the intima that penetrates into the media and splits longitudinally. Usually occurs in the thoracic aorta.

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14
Q

Aortic Dissection etiology

A

connective tissue disorder, aneurysm, HTN and trauma.

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15
Q

Aortic Dissection symptoms

A

Acute onset of tearing pain in the chest or abdomen. HTN (often discrepent) and anxiety. Neuro changes. Distal ischemia. acute cardiac failure. hypotenstion and shock. Hoarseness.

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16
Q

Type A Aortic Dissection

A

Ascending aorta +/- arch

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17
Q

Type B Aortic Dissection

A

Descending aorta only

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18
Q

Aortic Dissection diagnosis

A

spiral CT with contrast

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19
Q

Aortic Dissection complications

A

rupture, thrombosis/ischemia, aneurysm, re-enter (best case) or continue to extend.

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20
Q

Aortic Dissection Xray

A

Widened mediastinum, loss of aortic knob, globular heart, pleural capping or effusion.

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21
Q

Aortic Dissection risk factors

A

HTN, connective tissue disorder, pregnancy.

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22
Q

Aortic Dissection medical management

A

Reduce systolic BP to 100-120. Beta blockers THEN vasodilator (nipride). Pain control.

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23
Q

Aortic Dissection type A management

A

emergent surgery.

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24
Q

Aortic Dissection type B management

A

medical therapy unless complicated (failure of medical management, uncontrollable pain, progression, marfans)

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25
Q

AAA screening indications

A

Anyone with a family history needs an US.

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26
Q

AAA surgical indications

A

if greater than 5.5 cm or is expanding more than 0.5cm in 6-12 months.

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27
Q

AAA medical management

A

Follow up every 6-12 months.

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28
Q

AAA symptoms

A

Usually asymptomatic. Most common complaint is back pain.

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29
Q

Ruptured AAA symptoms

A

Abdominal pain, pulsatile tender abdominal mass, hypotension.

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30
Q

Chronic Aorto-iliac occlusive disease risk factors

A

Young, female, smoker, hyperlipidemia, congenitally smaller aorta, chronic lower limb ischemia.

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31
Q

chronic Aorto-iliac occlusive disease diagnosis

A

Angiogram or MRI/MRA

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32
Q

Chronic Aorto-iliac occlusive disease treatment

A

endovascular or aortic bypass surgery.

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33
Q

Acute Aorto-iliac occlusive disease cause

A

Vascular emergency, saddle embolism at bifurcation or in-situ thrombolism of already diseased segment.

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34
Q

Acute Aorto-iliac occlusive disease symptoms

A

Neuro deficit including paralysis, absent femoral pulses.

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35
Q

Acute Aorto-iliac occlusive disease treatment

A

Quick imaging and operation (aorto-bifemoral bypass).

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36
Q

Popliteal aneurysm

A

Rare, older males with co-morbidities. Greater than 2 cm pulsatile mass often with angulation.

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37
Q

Popliteal aneurysm complications

A

thrombosis, embolization (black toe syndrome), claudication, pressure symptoms.

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38
Q

Peripheral Arterial Disease (PAD)

A

Chronic arterial insufficiency of the lower extremities. Most common form of peripheral vascular disease. Athersclerotic in nature and are progressive.

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39
Q

Peripheral Arterial Disease (PAD) symptoms

A

claudication, rest pain (less than 50mmhg in the leg) usually in toes and dorsum of the foot. Dependent rubor. hair loss, atrophic skin, nail changes, ulcers. Pallor when elevated. Cool skin. Delayed capillary refill.

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40
Q

Leriche Syndrome

A

decreased femoral pulses, impotence, butt/thigh claudication (aorto-iliac disease)

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41
Q

Ankle Brachial Index

A

ankle systolic divided by the higher brachial systolic.

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42
Q

Ankle Brachial index classifications

A 
normal=1
mild=0.7-0.99
Moderate=0.5-0.7
severe= less than 0.5 
If over 1 think DM due to calcified vessels.
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43
Q

Peripheral Arterial Disease (PAD) most common veins affected

A

superficial femoral and popliteal.

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44
Q

Claudication classification

A 
mild= greater than 2 blocks
Moderate= one block 
Severe= less than one block
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45
Q

Peripheral Arterial Disease (PAD) treatment

A

Walking regimen, smoking cessation, lipid-lowering therapy, aspirin (or clopidogrel)

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46
Q

Treatment for sever claudication

A

pentoxifylline (trental) 400mg TID to help reduce viscosity and help the RBC move through the capillaries.
Cilostazol (pletal): phosphodiesterase III inhibitor shown to be more effective than trental

47
Q

Peripheral Arterial Disease (PAD) indications for surgery

A

affecting their lifestyle, rest ischemia, limb threat

48
Q

Limb threat

A

ABI that is less than 0.2

49
Q

Acute Artery Obstruction symptoms

A

Pain, pallor, paresthesia, paralysis, pulselessness.

50
Q

Acute Artery Obstruction Causes

A

Thrombus, embolism, hypercoagubility, external compression or artery (thoracic outlet syndrome).

51
Q

Acute Artery Obstruction treatment

A

emergency surgery or thrombolytic infusion. Heparin is given right away to keep it from getting worse.

52
Q

Compartment Syndrome Causes

A

Common after reperfusion of an ischemic limb. Usually in the calf.

53
Q

Compartment Syndrome symptoms

A

out of proportion pain, passive stretch pain, parasthesias, pokliothermia, paralysis, pulselessness

54
Q

Compartment Syndrome treatment

A

fasciotomy with delayed closure.

55
Q

Varicose veins cause

A

defective venous valves. Seen in people who are on their feet a lot.

56
Q

Varicose veins symptoms

A

Tired, heavy sensation. can be painful/burning/achy. Relieved with elevation. Can also have stasis dermatitis and edema.

57
Q

Varicose veins treatment

A

compression stockings, sclerotherapy, laser therapy, vein stripping.

58
Q

Chronic venous insufficiency Causes

A

valvular incompetence or some sort of damage (DVT or trauma).

59
Q

Chronic venous insufficiency treatment

A

elevation and compression. wound care with an unna boot if needed. Possible need for diuretics or antibiotics.

60
Q

Virchow’s triad

A

Stasis, vessel wall injury and hypercoagubility. Three things needed for thrombosis.

61
Q

Venous thromboembolism risk factors (chronic)

A

Chronic diseases (CHF, IBS, nephrotic syndrome), malignancy, obesity, antiphospholipid antibody syndrome, advanced age, smoking, myeloproliferative disorders

62
Q

Venous thromboembolism risk factors (transient)

A

surgery (ortho), trauma, immobilization, central lines, hospitalization, infections, prolonged travel.

63
Q

Venous thromboembolism risk factors (female specific)

A

pregnancy, post-partum, hormonal contraceptives, hormone replacement therapy.

64
Q

Venous thromboembolism risk factors (inherited)

A

factor V leiden mutation, prothrombin mutation, protein S deficiency, Protein C deficiency, antithrombin deficiency.

65
Q

DVT presentations

A

Can be asymptomatic. Swelling, pain, warmth, redness/dicoloration, palpable cord. Homan’s sign (not specific or sensitive).

66
Q

Wells criteria for DVT factors

A

cancer, immobilization, bedridden, tenderness, leg swelling, pitting edema, collateral veins.

67
Q

Wells criteria for DVT scoring

A

2-8 high probability
1-2 moderate
-2-0 low

68
Q

D-Dimer

A

Degradation product of cross-linked fibrin. Greater than 500 ng/ml. Seen in almost all patients with a DVT/PE but not specific.

69
Q

D-dimer incications

A

Used to rule out DVT/PE. Used when suspicion is low or when ultrasound is negative. A negative D-dimer is insufficient as a stand-alone test to rule out DVT if suspicion is high.

70
Q

Contrast venography indications

A

Used when other studies are inconclusive. Not used as initial screening tool because it is invasive.

71
Q

Impedance plethysmography

A

measures small changes in electrical resistance that reflect blood volume changes. Indirectly indicates a DVT

72
Q

Impedance plethysmography indications

A

Not first choice because while it is non invasive it is not widely available. Is preferred test for recurrent DVT though.

73
Q

Compression ultrasound indications

A

test of choice for high suspicion of DVT. Not great for proximal veins though.

74
Q

Low probability of DVT diagnostics

A

First D-dimer and if positive then ultrasound. If negative DVT is ruled out.

75
Q

High probability of DVT diagnostics

A

Ultrasound if positive=DVT. If negative then do a D-dimer if negative=no DVT. If the D-dimer is positive have the patient follow up in a week.

76
Q

DVT Treatment

A

Anticoagulation therapy, Early ambulation, prevention (compression stockings)

77
Q

Superficial thrombophlebitis

A

No edema and don’t need anticoagulation. Not a DVT.

78
Q

Pulmonary embolism

A

obstruction of the pulmonary artery or one of it’s branches by material that originated somewhere else. DVT is the most common cause. More common in males.

79
Q

Hemodynamic instability

A

Systolic BP less than 90mmHG 40mmHg within 15 minutes. More likely to die of the PE.

80
Q

PE symptoms

A

DYSNPNEA and PLEURITIC PAIN, DVT symptoms, cough (hemoptysis).

81
Q

PE Signs

A

TACHYPNEA, tachycardia, decreased breath sounds, accentuated pulmonic component of S2 and JVD.

82
Q

Hemodynamically stable diagnosis of PE

A

Wells criteria for PE, D-Dimer, and diagnostic imaging (CTA)

83
Q

Hemodynamically unstable diagnosis of PE

A

EKG to make a presumptive diagnosis of PE

84
Q

Wells criteria for PE

A

DVT symptoms, tachycardia, immobiliation, previous DVT, hemoptysis, malignancy.

85
Q

Wells criteria for PE scoring

A

greater than 4=PE likely

Less that 4= PE unlikely

86
Q

Pulmonary angiography

A

Historically was the gold standard for PE diagnosis but not now. Too invasive with high IV contrast load.

87
Q

CT Pulmonary Angiography

A

Test of choice for PE diagnosis. sensitive and specific. Non-invasive. Contraindicated if contrast allergy or renal dysfunction.

88
Q

Ventilation-perfusion scan

A

Sensitive but not specific. High number of false positives. Used for patients with contrast allergy or renal dysfunction. Also used for those that had normal chest radiography.

89
Q

EKG for PE

A

Non-specific ST-segment and T-wave changes. S1Q3T3 pattern (10%).

90
Q

Chest Xray for PE

A

not sensitive or specific but still done on everyone. Hamptons hump (opacity) and westermark sign (oligemia)

91
Q

PERC Rule

A

Alternative to using D-dimer to rule out a PE. Has to have all eight: less than 50 yo, HR less than 100, sats above 95%, no hemoptysis, no estrogen use, no prior DVT/PE, no unilateral leg swelling, no recent surgery/trauma/hospitalization.

92
Q

Lovenox

A

SQ low molecular weight heparin.

93
Q

Coumadin

A

oral warfarin

94
Q

Fondaparinux (arixtra)

A

SQ factor Xa inhibitor

95
Q

rivaroxaban (xareltol)

A

Oral factor Xa inhibitor

96
Q

apixaban (eliquis)

A

Oral factor Xa inhibitor

97
Q

edoxaban (Savaxsa)

A

Oral factor Xa inhibitor

98
Q

dubigatran (pradaxa)

A

Oral direct thrombin inhibitor

99
Q

Initial anticoagulation therapy

A

First ten days. SQ LMW heparin, SQ fondaparinux or IV UFH (less common)

100
Q

Initial anticoagulation therapy with UFH indications

A

severe renal failure or those more likely to need anticoagulation reversal IV UFH is preferred.

101
Q

Initial anticoagulation therapy with SQ LMW heparin indications

A

pregnancy and malignancy

102
Q

Long term anticoagulation therapy

A

Warfarin with a target INR of 2-3. Warfarin is slow acting so you need an additional anticoagulant until the warfarin is providing anticoagulation.

103
Q

Long term anticoagulation therapy alternatives

A

Oral factor Xa inhibitors and oral direct thrombin inhibitors are used so patients don’t have to monitor their INR. But need to take into account the possible need for anticoagulation reversal (trauma, elderly, alcoholics).

104
Q

Heparin reversal

A

Protamine (only parital with LMW heparin)

105
Q

Warfarin reversal

A

vitamin K and fresh frozen plasma

106
Q

Factor Xa inhibitor reversal

A

NONE

107
Q

Direct thrombin inhibitors reversal

A

Idarucizumab is a brand new drug on the market.

108
Q

First episode treatment duration

A

At least 3 months. If provoked anticoagulation therapy should continue until the risk factor is modified (pregnancy).

109
Q

Indefinite anticoagulation indications

A

first/recurrent episodes of unprovoked DVT/PE especially with proximal DVTs. Underlying thrombophillia.

110
Q

Protein C, S or antithrombin deficiency Lab indication

A

Consider if less than 50 years old and with a family history.

111
Q

Factor V leiden or prothrombin mutation tests

A

PCR for the mutation. Thrombosis on OCPs, cerebral vein thrombus, DVT/PE in white population.

112
Q

Anriphospholipid antibody syndrome tests

A

Anti-cariolipin antibody, anti-beta-2 glycoprotein antibody, lupus anticoagulant. For unexplained VTE, CVA/TIA at less than 50 years old, recurrent VTE, unusual site, artery and venous thrombosis, thrombocytopenia, recurrent early pregnancy loss.

113
Q

IVC filter indications

A

Anticoagulation is contraindicated, recurrent PE even with anticoagulation, hemodynamic/respiratory compromise where another PE would be life threatening.

114
Q

Thrombolytic use for PE indications

A

unstable patients with shock , hypoxemia, V/Q deficit, RV dysfunction, extensive DVT. (strptokinase, urokinase, recombinant tissue plasminogen activator).

Clinical Medicine (7 decks)

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